A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Document the infiltration.

Stop the infusion.

Elevate the arm.

Apply a warm compress.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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Correct Answer is B

Explanation

The correct answer is B. Encourage the client to be assertive. Dependent personality disorder is characterized by excessive reliance on others for emotional and practical support, fear of abandonment, difficulty expressing disagreement, and low self-esteem. The nurse should instruct the caregiver to help the client develop autonomy and self-confidence by encouraging them to express their opinions, make their own choices, and take responsibility for their actions.

A. Client reports a decreased appetite B. Client isolates themselves from their family and friends C. Client expresses an inability to experience pleasure D. Client reports intermittent depressed mood

Correct Answer is B

Explanation

Answer: B. Client isolates themselves from their family and friends

Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.

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A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in theteaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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